BSC Medical Form 2023

Are you filling this out on behalf of a minor?

YesNo
Name*

First NameLast Name
Mainland Address*

Street Address

Street Address 2

TownCounty

Post Code
Isle of Wight Address*

Street Address

Street Address 2

TownCounty

Post Code
Phone Number*
Please enter a valid phone number.
Emergency Contact Name*

First NameLast Name
Emergency Phone Number*
Please enter a valid phone number.
Emergency Email Address*
Please enter a valid email address
Have You ever suffered from any of the following conditions:

NoneHeart conditionsFits, fainting or blackoutsSevere headachesDiabetesTravel/Sea sicknessAllergies to medicationAny other allergiesOther illnesses or disabilitiesAsthma/bronchitisOther
It is your responsibility to make us aware of any medical conditions/requirements or special educational needs which may need to be considered for the duration of the course. Please could you therefore provide us with as much detail as possible about your specific requirements, in order to help us deliver the training most suitable to their needs, provided that we are able to do this without compromising the standard, quality and integrity of courses and assessments that we provide.
If you have answered yes to the above please provide details:
Are you currently taking any medication, if so will we need to store/ administer any?
Brief Details
Are you suffering/recovering from any injuries which may affect your sailing or powerboating?
Brief Details
Is the sailor:*

Able to swimWater confidentUnconfident in water
Can you swim over 25m in light clothing?*

YesNo
We often use photographs and video for course training.

Photographs may also be used on the Club website, Club publications or future training presentations.

Photographs will generally not be published outside the Club without your permission
Do you give consent to having your picture taken?*

YesNo
Do you give consent to your picture being used on club website or social media pages*

YesNo
I have read and accept the contents and terms of the Course Conditions and of the booking form; that my dependent is fit to take part in the course and I will be responsible for him/her throughout the course, and that the boat(s) detailed meet(s) the course requirements, will be presented for confirmation as such on the relevant day of briefing and is/are seaworthy, insured and equipped appropriately.

In the event of an injury, I give permission to the organisers of the activities during the period of the course to administer any relevant treatment or medication to the above named participant when or if deemed necessary.

In an emergency situation, I authorise the organisers to allow the Cadet to be taken off-site to receive medical attention and give full permission for any treatment required to be carried out in accordance with the Medical Professional's diagnosis. I understand that I shall be notified as soon as possible, of any medical treatment given.
Please confirm the person submitting this form is over 18*

Yes
Signature*

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